CONTRACT AND GRANT DISCLOSURE AND CERTIFICATION FORM
Failure to complete all of the following
information may result in a delay in obtaining a contract, lease, purchase agreement, or grant award with any Arkansas State Agency.
SUBCONTRACTOR: SUBCONTRACTOR NAME:
Yes No
IS THIS FOR:
TAXPAYER ID NAME:
Goods? Services? Both?
YOUR LAST NAME: FIRST NAME: M.I.:
ADDRESS:
CITY: STATE: ZIP CODE: --- COUNTRY:
AS A CONDITION OF OBTAINING, EXTENDING, AMENDING, OR RENEWING A CONTRACT, LEASE, PURCHASE AGREEMENT,
OR GRANT AWARD
WITH ANY ARKANSAS STATE AGENCY, TH
E FOLLOWING INFORMATION MUST BE DISCLOSED:
F OR I NDIVIDUALS*
Indicate below if: you, your spouse or the brother, sister, parent, or child of you or your spouse is a current or former: member of the General Assembly, Constitutional Officer, State Board or Commission
Member, or State Employee:
Mark (√) For How Long?
What is the person(s) name and how are they related to you?
[i.e., Jane Q. Public, spouse, John Q. Public, Jr., child, etc.]
Position Held
Current Former
[senator, representative, name of
board/ commission, data entry, etc.]
From
MM/YY
To
MM/YY
Person’s Name(s) Relation
General Assembly
Constitutional Officer
State Board or Commission
Membe
State Employee
F OR AN E NTITY (BUSINESS)*
Indicate below if any of the following persons, current or former, hold any position of control or hold any ownership interest of 10% or greater in the entity: member of the General Assembly, Constitutional
Officer, State Board or Commission Member, State Employee, or the spouse, brother, sister, parent, or child of a member of the General Assembly, Constitutional Officer, State Board or Commission
Mark (√) For How Long?
What is the person(s) name and what is his/her % of ownership interest and/or
what is his/her
osition of control?
Position Held
Current Former
[senator, representative, name of
board/commission, data entry, etc.]
From
MM/YY
To
MM/YY
Person’s Name(s)
Ownership
Interest (%)
Position of
Control
General Assembly
Constitutional Officer
State Board or Commission
Membe
State Employee